Allergic rhinitis: clinical practice guideline. Committee on Practice Standards, American Academy of Otolaryngic Allergy

Prunetin inhibits lipopolysaccharide-induced inflammatory cytokine production and MUC5AC expression by inactivating the TLR4/MyD88 pathway in human nasal epithelial cells

Allergic rhinitis (AR) is a chronic upper respiratory disorder characterized by inflammation of the nasal mucosa. Prunetin is an O-methylated isoflavone, which has been found to possess anti-inflammatory activity. The aim of the current study was to evaluate the effect of prunetin on inflammatory cytokine and mucus production and its underlying mechanism in nasal epithelial cells. Results showed that treatment with prunetin (10, 30, and 50 μM) inhibited lipopolysaccharide (LPS)-induced expression and secretion of interleukin (IL)-6, IL-8, and mucin 5 AC (MUC5 AC) in RPMI2650 cells, and attenuated the effect of LPS on toll-like receptor 4 (TLR4) and myeloid differentiation primary response 88 (MyD88) expression. TAK-242 (an inhibitor of TLR4) treatment or TLR4 knockdown attenuated LPS-induced expression and secretion of IL-6, IL-8 and MUC5 AC. In conclusion, prunetin inhibited LPS-induced inflammatory cytokine production and MUC5 AC expression and secretion by inactivating the TLR4/MyD88 pathway in human nasal epithelial cells. These results suggested that prunetin might be a useful agent in the treatment of AR.

Non-adherence to subcutaneous allergen immunotherapy: inadequate health insurance coverage is the leading cause

BACKGROUND

To sustain the long-lasting beneficial effects of subcutaneous allergen immunotherapy, the recommended duration of treatment is 3 to 5 years. Nevertheless, many patients discontinue allergy injections prematurely and therefore might not appreciate the full therapeutic benefit.

OBJECTIVE

To examine factors leading to premature discontinuation of subcutaneous allergen immunotherapy (cessation before completion of the recommended duration).

METHODS

Patients who discontinued immunotherapy before the completion of the prescribed duration and received their final injection from January 2008 through September 2013 were contacted to identify the reason for stopping the allergy injections. Phase of treatment (escalation or maintenance) was used to measure the duration of treatment at the time of cessation and patients were grouped accordingly.

RESULTS

The study population consisted of 555 patients with allergic rhinitis and/or asthma who terminated immunotherapy prematurely. Two hundred thirteen (38%) were men and 342 (62%) were women. The following reasons were cited by patients for non-adherence to immunotherapy: requirement of copayment for allergy injections and/or payment for allergen extract by their health insurer (40%); inconvenience of travel (15%); change of residence (8%); concurrent health problems (5%); patient-perceived ineffectiveness (4%); patient-perceived lack of need to continue immunotherapy (2%); adverse effects from injection (local reaction 1%; systemic allergic reaction 0.5%); and trial of alternative medicine (0.1%). The remaining 24.4% did not provide a reason for discontinuation.

CONCLUSION

Of the various factors, inadequate reimbursement for allergen extract and allergy injections by health insurers is the most common reason cited for non-adherence to subcutaneous allergen immunotherapy.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Why otolaryngologists and asthma are a good match: the allergic rhinitis-asthma connection

Consideration of the unified airway model when managing patients with rhinitis and or asthma allows a more comprehensive care plan and therefore improved patient outcomes. Asthma is linked to rhinitis both epidemiologically and biologically, and this association is even stronger in individuals with atopy. Rhinitis is not only associated with but is a risk factor for the development of asthma. Management of rhinitis improves asthma control. Early and aggressive treatment of allergic rhinitis may prevent the development of asthma. In patients with allergic rhinitis that is not sufficiently controlled by allergy medication, allergen-directed immunotherapy should be considered.

Total serum immunoglobulin E as a marker for missed antigens on in vitro allergy screening

BACKGROUND

The diagnosis of inhalant allergies involves a medical history, physical exam, and allergen sensitivity testing; allergen sensitivity can be assessed by a specific immunoglobulin E (IgE) screen for inhalant allergens. Some patients with clinical suspicion for inhalant allergies have a negative specific IgE screen, but high total IgE. We theorize that elevated total IgE may indicate a false-negative screen caused by "missed allergens" not initially identified.

METHODS

Study patients with a negative allergy screen and elevated IgE (>116 kU/L) were identified (n = 26). Control patients (n = 26) were defined as having a negative screen and an IgE <2.95 kU/L. Both groups were tested with an expanded specific IgE panel and completed a questionnaire about other causes of elevated IgE.

RESULTS

The expanded panel was positive for inhalant allergens in 4 study patients (15%) and 0 control patients (p = 0.037). Within the study patients, 50% had asthma and 76.9% had chronic sinusitis. Only 2 control patients had asthma (11.5%), p = 0.003; 4 (19.2%) reported chronic sinusitis, p < 0.0001. Food allergen sensitivity was identified in 5 study patients and 1 control, p = 0.083.

CONCLUSION

This pilot study evaluated patients clinically suspected of allergy with a negative inhalant IgE screen. Those with a high total IgE were more likely to have a missed inhalant allergen on expanded testing, as well as asthma and chronic sinusitis, compared to those with a low total IgE. Further investigation of "missed antigen" and the role of chronic respiratory inflammatory disease in patients with elevated total IgE is warranted.

Inadequate health insurance coverage: a major factor in premature discontinuation of subcutaneous immunotherapy for allergic rhinitis

We conducted a study of 155 patients with allergic rhinitis who prematurely discontinued subcutaneous allergen immunotherapy to determine the reasons for their discontinuation. The most commonly cited factor, which was cited by 62 patients (40.0%), was the issue of cost-specifically, inadequate or nonexistent insurance coverage. Studies have shown that subcutaneous allergen immunotherapy is more cost-effective than pharmacologic treatment for patients with allergic rhinitis. Therefore, improved insurance coverage for this treatment of proven efficacy would not only improve quality of life, it would also be economically beneficial to the healthcare system in general.

Decreased FoxP3 gene expression in the nasal secretions from patients with allergic rhinitis

OBJECTIVE

To determine whether patients with allergic rhinitis have altered FoxP3 gene expression and/or mutations.

STUDY DESIGN AND METHODS

We collected nasal secretions from 14 volunteers (five of whom have allergic rhinitis) and five ENT allergy patients. Total RNA was isolated from these nasal secretions. The gene expression levels of FoxP3 were quantified by both semi-quantitative RT-PCR and real-time PCR using Actin as a housekeeping gene. The cDNA fragments amplified by RT-PCR were analyzed by DNA sequencing.

RESULTS

We found that patients with allergic rhinitis had significantly lower FoxP3 mRNA compared to nonallergic controls (P < 0.01). In addition, we found a point mutation in the FoxP3 gene from a patient who not only has severe allergic rhinitis, but also has asthma. This mutation locates in a highly conserved region of FoxP3 gene and partially impaired FoxP3 functions.

CONCLUSION

Our data indicate that either reduced FoxP3 gene expression or impaired FoxP3 functions are involved in the development of allergic disease in humans.

Sublingual immunotherapy: a novel, albeit not so new, immunotherapy treatment modality

BACKGROUND

Specific allergy immunotherapy traditionally has been thought of as subcutaneous injection immunotherapy (SCIT). There also are noninjection routes for the administration of immunotherapy. The best-known and studied of these noninjection routes is the sublingual route, usually known as sublingual immunotherapy (SLIT). SLIT has been in use for many decades; however, to this date, it is not well known to the majority of allergy practitioners in this country. The purpose of this study is to help change this perception so that SLIT eventually can be considered one more tool in the allergist's armamentarium.

METHODS

A literature review was performed. It included articles from the early American clinicians and present publications that are mostly of European origin.

RESULTS

It will become clear to the reader that the key features of SLIT are its efficacy, great safety, and simplicity of administration.

CONCLUSION

SLIT is a safe treatment modality that should be considered as a useful additional tool in the therapeutic armamentarium.

Efficacy Comparison of Multiple-Antigen Subcutaneous Injection Immunotherapy and Multiple-Antigen Sublingual Immunotherapy

We performed an observational study to determine whether allergen-specific sublingual immunotherapy (SLIT) is as effective as allergen-specific subcutaneous injection immunotherapy (SCIT). Our study population was comprised of 66 patients who had been taking SLIT. Of this group, 36 patients had switched to SLIT after having been treated with SCIT (group I), while the remaining 30 patients had received SLIT only (group II). A questionnaire was used to evaluate the results of treatment. In group I, 33 patients (92%) gave SLIT a favorable rating; 27 of these patients (75%) said it was just as effective as SCIT, and 6 (17%) said it was actually superior (the remaining 3 patients [8%] said that SCIT was better). In group II, 27 of 30 patients (90%) said they had attained symptom relief with SLIT; 21 (70%) said that the relief had been very significant. Overall, 60 of the 66 patients (91 %) expressed various degrees of satisfaction with SLIT. We believe that our SLIT protocol, which is based on established guidelines for SCIT administration, is an effective, safe, well-tolerated, and easy-to-use regimen. Future prospective studies of larger groups are clearly indicated.

Critical look at the clinical practice guidelines for allergic rhinitis

Allergic rhinitis (AR) is a major health concern and numerous guidelines have been developed to standardize and to improve the management of this disease. As in many other areas of medicine, the methodology of the AR guidelines has evolved from opinion-based to evidence-based medicine. Although evidence-based medicine has many benefits, it also has limitations and cannot cancel the value of the individual clinical expertise. More important than the methodology of guideline development is the efficacy of guidelines to change patient and physician behaviour and to improve clinical outcomes. At present, however, studies on the effectiveness of guidelines are few. The International Consensus on Rhinitis from 1994 is the only guideline for AR that has been assessed for its effects on health outcomes. Furthermore, there is a lack of valid and reliable instruments to assess physician's and patient's attitude towards and compliance with guideline recommendations. There is no single effective way to ensure the use of guidelines into practice, but a carefully developed and multifaceted dissemination and implementation strategy and targeting and adapting guideline recommendations to the local and individual level are key elements. The final and most important step of putting guidelines into practice occurs at the level of the patient. Patients should be considered as effective partners in health care. Education of the patient and efforts to change patient's behaviour can maximize compliance, increase satisfaction and optimize health outcomes.

Evaluation of the optimal oral antihistamine for patients with allergic rhinitis

Because of its bothersome symptoms, allergic rhinitis (AR) is 1 of the top 10 reasons for patient visits to primary care physicians. This highly prevalent disease also results in loss of productivity, both at work and in school. Oral antihistamines are one of the most frequently prescribed medications for the management of AR and, with several agents available, it is important to discern the specific benefits and detriments of each. To assess the differences in efficacy and safety factors among antihistamines, the Individual therapeutic window of each agent can be used as a comparative reference tool because it defines the dose range over which an antihistamine is efficacious and free of adverse effects. As such, the therapeutic window includes both undesired effects, such as sedation, and desired properties, such as rapid onset of action, long duration of efficacy, broad age range of applicability, and potential to Improve quality of life. Therefore, agents with broad therapeutic windows, based on both efficacy and safety, are expected to be more favorable; this therapeutic window should be understood by the primary care physician when prescribing a medication.

Cetirizine: a review of its use in allergic disorders

Cetirizine is a selective, second-generation histamine H1 receptor antagonist, with a rapid onset, a long duration of activity and low potential for interaction with drugs metabolised by the hepatic cytochrome P450 system. Cetirizine was generally more effective than other H1 receptor antagonists at inhibiting histamine-induced wheal and flare responses. Cetirizine is an effective and well tolerated agent for the treatment of symptoms of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR) and chronic idiopathic urticaria (CIU) in adult, adolescent and paediatric patients. In adults with these allergic disorders, cetirizine was as effective as conventional dosages of ebastine (SAR, PAR, CIU), fexofenadine (SAR), loratadine (SAR, CIU) or mizolastine (SAR). This agent was significantly more effective, and with a more rapid onset of action, than loratadine in 2-day studies in environmental exposure units (SAR). In paediatric patients, cetirizine was as at least as effective as chlorphenamine (chlorpheniramine) [SAR], loratadine (SAR, PAR) and oxatomide (CIU) in the short term, and more effective than oxatomide and ketotifen (PAR) in the long term. Cetirizine was effective in reducing symptoms of allergic asthma in adults and reduced the relative risk of developing asthma in infants with atopic dermatitis sensitised to grass pollen or house dust mite allergens. It had a corticosteroid-sparing effect in infants with severe atopic dermatitis and was effective in ameliorating reactions to mosquito bites in adults. Cetirizine was well tolerated in adults, adolescents and paediatric patients with allergic disorders. In adult, adolescent and paediatric patients aged 2-11 years, the incidence of somnolence with cetirizine was dose related and was generally similar to that with other second-generation H1 receptor antagonists. Although, its sedative effect was greater than that of fexofenadine in some clinical trials and that of loratadine or fexofenadine in a postmarketing surveillance study. In infants aged 6-24 months, the tolerability profile of cetirizine was similar to that of placebo. Cetirizine did not have any adverse effects on cognitive function in adults, or cognitive function, behaviour or achievement of psychomotor milestones in paediatric patients. Cetirizine was not associated with cardiotoxicity.

CONCLUSION

Cetirizine is well established in the treatment of symptoms of SAR, PAR or CIU. It demonstrated a corticosteroid-sparing effect and reduced the relative risk of developing asthma in sensitised infants with atopic dermatitis. Cetirizine was effective in the treatment of allergic cough and mosquito bites; however, its precise role in these indications has yet to be clearly established. On the basis of its favourable efficacy and tolerability profile and rapid onset of action, cetirizine provides an important option for the treatment of a wide range of allergic disorders.

In vitro testing for allergy diagnosis

The measurement of specific IgE antibodies has progressed so that highly reproducible, accurate, and quality-controlled tests are available [62]. These tests can certainly assist all physicians in evaluating allergic problems and are likely to be used widely in the future. Continued research is allowing the refinement of these tests as well as increasing the understanding of allergens and allergic disease. In vitro testing techniques are major assets to allergy care. Either in vitro or skin methods are appropriate modalities for the diagnosis of allergic rhinitis [45]. When the merits of the allergy skin test and in vitro tests for diagnosis of specific allergens are compared, the following statements are considered to be correct at this time: 1. Optimally performed skin tests and in vitro tests detect IgE E antibody accurately and reproducibly. 2. Results of both tests correlate equally well with allergic signs and symptoms produced by exposure to the specifically tested allergen. 3. Both tests can be used as grounds for instituting avoidance therapy and immunotherapy efficiently and economically.

A Comparison of Skin Endpoint Titration and Skin-Prick Testing in the Diagnosis of Allergic Rhinitis

Among the many methods of allergy diagnosis are intradermal testing (IDT) and skin-prick testing (SPT). The usefulness of IDT has been called into question by some authors, while others believe that studies demonstrating that SPT was superior might have been subject to bias. We conducted a study to compare the validity of SPT and IDT—specifically, the skin endpoint titration (SET) type of IDT—in diagnosing allergic rhinitis. We performed nasal provocation testing on 62 patients to establish an unbiased screening criterion for study entry. Acoustic rhinometric measurements of the nasal responses revealed that 34 patients tested positive and 28 negative. All patients were subsequently tested by SET and SPT. We found that SPT was more sensitive (85.3 vs 79.4%) and more specific (78.6 vs 67.9%) than SET as a screening procedure. The positive predictive value of SPT was greater than that of SET (82.9 vs 75.0%), as was the negative predictive value (81.5 vs 73.0%). None of these differences was statistically significant; because of the relatively small sample size, our study was powered to show only equivalency. The results of our study suggest that the information obtained by the SET method of IDT is comparable to that obtained by SPT in terms of sensitivity, specificity, and overall performance and that both SET and SPT correlate well with nasal provocation testing for ragweed. Therefore, the decision as to which to use can be based on other factors, such as the practitioner's training, the desire for quantitative results, the desire for rapid results, and the type of treatment (i.e., immunotherapy or pharmacotherapy) that is likely to be chosen on the basis of test results.

Clinical practice guidelines and specific antigen immunotherapy

Allergy immunotherapy is a safe, effective treatment modality in selected patients. The length of therapy and the wide variety of patient sensitivities make it difficult to develop and test evidence-based guidelines in all areas of immunotherapy. A review of techniques and the evidence supporting them is provided in this article.

Adding allergy to your practice

The ability to blend the management of allergic disease into the general treatment of head and neck disease is core to the otolaryngologist's role as regional specialist of the upper aerodigestive tract. Allergy training is now considered an integral component of the residency curriculum established by the American Board of Otolaryngology. By obtaining any needed additional training through organizations such as the AAOA and by validating that education by obtaining fellowship status in the AAOA, the postgraduate otolaryngologist who adds allergy to his or her practice will find the techniques to be safe, effective, and of great benefits to patients.

The importance of glycerin-containing negative control tests in allergy research studies that use intradermal skin tests

OBJECTIVE

We sought to assess skin whealing with glycerin-containing control injections for intradermal skin tests.

DESIGN

Observational.

METHODS

Wheal sizes were measured at 0, 10, and 15 minutes after intradermal injection of 0.01 and 0.02 mL of phenolated normal saline and 0.5% and 5% concentrations of glycerin in the same quantity of phenolated saline.

RESULTS

Intradermal injection of 0.01 mL of phenolated saline produced an average 4.9-mm wheal, which expanded to 5.2 mm at 10 minutes and to 6.0 mm at 15 minutes. Intradermal injection of 0.02 mL of phenolated saline produced a 6.4-mm wheal, which expanded to 7.0 mm at 10 minutes and 8.0 mm at 15 minutes. The addition of glycerin produced proportionally larger wheals.

CONCLUSIONS

Because glycerin increases whealing beyond that with phenolated saline, skin tests containing glycerin must be compared with glycerin-containing negative controls. Intradermal skin tests that fail to compare findings in this manner contain an inherent methodologic flaw and are uninterpretable.

Cetirizine/pseudoephedrine

Cetirizine is the carboxylated metabolite of hydroxyzine, and has high specific affinity for histamine H(1) receptors. Pseudoephedrine is a sympathomimetic drug that acts directly on alpha-adrenergic receptors. black triangle Cetirizine/pseudoephedrine 5/120 mg twice daily was significantly more effective than intranasal budesonide 100 microg or placebo at improving nasal obstruction, nasal patency and reducing the volume of nasal secretion, and was significantly more effective than intranasal xylometazoline 0.1% with respect to nasal secretion, during house dust mite faeces challenge in three randomised, cross- over studies among volunteers with seasonal or perennial rhinitis. The onset of action of cetirizine/pseudoephedrine was reported to be approximately 30 minutes. black triangle The bioavailability of cetirizine and pseudoephedrine is similar after administration of cetirizine/pseudoephedrine 5/120 mg bilayer tablets or coadministration of cetirizine 5 mg tablets plus pseudoephedrine sustained-release (SR) 120 mg caplets. black triangle Cetirizine 5mg plus pseudoephedrine SR 120 mg twice daily for 2 to 3 weeks was significantly more effective than each drug given alone at reducing mean total symptom scores for seasonal or perennial allergic rhinitis in two randomised, double-blind, multicentre trials. In both studies, the mean proportion of days during which the five measured symptoms (nasal obstruction, sneezing, rhinorrhoea, nasal pruritus and ocular pruritus) were absent or mild was significantly greater in recipients of the cetirizine plus pseudoephedrine SR. black triangle In one study, cetirizine 5 mg plus pseudoephedrine SR 120 mg was significantly more effective at reducing nasal obstruction than either drug alone. black triangle Cetirizine 5mg plus pseudoephedrine SR 120 mg twice daily for 2 to 3 weeks was well tolerated in patients with seasonal or perennial allergic rhinitis. The most common adverse events were dry mouth, insomnia, headache, somnolence, asthenia and nervousness.

Ebastine: an update of its use in allergic disorders

Ebastine is a second-generation antihistamine which undergoes transformation to its active metabolite, carebastine. Its antihistaminic and antiallergic effects have been demonstrated in in vitro and in vivo studies, in addition to data obtained from clinical trials. Patients with allergic rhinitis or chronic idiopathic urticaria experienced significant improvement in their symptoms with ebastine 10 or 20 mg once daily. Some studies in patients with seasonal allergic rhinitis (SAR) have indicated trends towards greater efficacy with the 20 mg than the 10 mg dose, although only 1 study has shown statistically significant benefits. In comparative trials in patients with SAR, ebastine 10 mg was as effective as most other second-generation antihistamines, including astemizole, azelastine, cetirizine, loratadine and terfenadine. Ebastine 20 mg/day was significantly superior to loratadine 10 mg/day in patients with SAR according to effects on secondary efficacy variables in comparative studies; 1 study found significantly greater changes from baseline in mean total symptom score with ebastine 20 mg (-43 vs -36% with loratadine, p = 0.045). In patients with perennial allergic rhinitis, ebastine 10 or 20 mg daily was significantly more effective than loratadine in reducing total symptom scores from baseline 1 comparative study. There have been no reports of serious adverse cardiac effects during ebastine therapy. Increases in corrected QT interval have been observed during clinical trials; however, these have not been considered clinically significant and were generally of similar magnitude to those seen with loratadine. The normal diurnal variation in QTc interval and the problems associated in correcting for changes in heart rate also complicate assessment of this issue. The incidence of adverse events during ebastine treatment is not significantly greater than that observed with placebo or other second-generation antihistamines.

CONCLUSIONS

Ebastine 10 mg daily is a well tolerated and effective treatment for allergic rhinitis and chronic idiopathic urticaria. At this dosage, it is as effective as the other second-generation antihistamines against which it has been compared. Ebastine 20 mg has similar tolerability to the 10 mg dose, and trends towards greater efficacy with the higher dose have been shown in some studies. Ebastine does not appear to be associated with any significant cardiac adverse events. Ebastine is a useful treatment option for patients with allergic rhinitis or chronic idiopathic urticaria.

Evaluation and management of allergic rhinitis

Allergic rhinitis is a problematic disorder that is common. The practicing physician recognizes the majority of the overt clinical symptoms of sneezing, nasal itching, postnasal discharge, and eye symptoms but may not be attuned to the more subtle symptoms of lethargy, headache, and loss of productivity they create. Food sensitivities may complicate the evaluation and treatment of the sensitive patient, and frequently the idea of foods causing problems with rhinitis is ignored. For most patients, practical medications are beneficial in reducing symptoms without producing the side effects of sedation. The newer topical nasal steroids are becoming the first line of therapy, and nonsedating antihistamines are still useful because they have few side effects. Immunotherapy is recommended for treatment failures in the appropriate patient. Specialty referral then should be considered.

The stuffy nose and rhinitis

The congested nose may represent a mild nuisance or be indicative of a serious health condition. Familiarity with appropriate methods of evaluation and testing can help avoid diagnostic pitfalls and make an accurate, timely assessment of the patient's condition.

Intranasal azelastine. A review of its efficacy in the management of allergic rhinitis

Azelastine, a phthalazinone compound, is a second generation histamine H1 receptor antagonist which has shown clinical efficacy in relieving the symptoms of allergic rhinitis when administered as either an oral or intranasal formulation. It is thought to improve both the early and late phase symptoms of rhinitis through a combination of antihistaminic, antiallergic and anti-inflammatory mechanisms. Symptom improvements are evident as early as 30 minutes, after intranasal administration of azelastine [2 puffs per nostril (0.56mg)] and are apparent for up to 12 hours in patients with seasonal allergic rhinitis (SAR). The effect on nasal blockage is variable: in some studies objective and/or subjective assessment showed a reduction in blockage, whereas in other studies there was no improvement. Intranasal azelastine 1 puff per nostril twice daily is generally as effective as standard doses of other antihistamine agents including intranasal levocabastine and oral cetirizine, ebastine, loratadine and terfenadine at reducing the overall symptoms of rhinitis. The relative efficacies of azelastine and intranasal corticosteroids (beclomethasone and budesonide) remain unclear. However, overall, the corticosteroids tended to improve rhinitis symptoms to a greater extent than the antihistamine. Azelastine was well tolerated in clinical trials and postmarketing surveys. The most frequently reported adverse events were bitter taste, application site irritation and rhinitis. The incidence of sedation did not differ significantly between azelastine and placebo recipients and preliminary report showed cardiovascular parameters were not significantly altered in patients with perennial allergic rhinitis (PAR).

CONCLUSION

Twice-daily intranasal azelastine offers an effective and well tolerated alternative to other antihistamine agents currently recommended for the symptomatic relief of mild to severe SAR and PAR in adults and children (aged > or = 12 years in the US; aged > or = 6 years in some European countries including the UK). The rapid onset, confined topical activity and reduced sedation demonstrated by the intranasal formulation of azelastine may offer an advantage over other antihistamine agents, although this has yet to be confirmed.

Evolution to current otolaryngic allergy techniques

The evolution of current otolaryngic allergy techniques for the diagnosis and management of inhalant and food allergens is presented in this article. Skin titration, in vivo diagnostic techniques, and symptom-relieving immunotherapy are emphasized for the former sensitivities and oral challenge tests, skin titration, and elimination or rotary diets for the latter.

Overview of otolaryngic allergy management. An eclectic and cost-effective approach

Ear, nose, and throat allergic assessment plays an integral role in the evaluation and care of approximately 25% of patients seen in a general otolaryngology practice. With the advances in health care delivery and the influence of managed care organizations, physicians are asked to render cost-effective evaluation and management of their patients. This article examines the economic issues and historical data regarding the work-up of patients with suspected allergic problems. Relative cost-benefits of different modalities of treatments, including avoidance techniques, pharmacotherapy, and immunotherapy, are discussed.

Allergy immunotherapy

Specific immunotherapy for allergy has been used for over eight decades. Despite this history, controversy continues over techniques, indications, and the eventual outcomes. This article reviews immunotherapy techniques available to the various practitioners of allergy care. Safety recommendations, indications for therapy, and available measurements for outcomes are also discussed.

Allergic rhinitis. Options for pharmacotherapy and immunotherapy

A trial of allergy medication can be both diagnostic and therapeutic in a patient with suspected allergic rhinitis, but with so many treatment options, it is sometimes difficult to know where to start. In this second of two articles on allergic rhinitis, Dr Ferguson provides information on efficacy and costs for various allergy drugs and discusses when to consider immunotherapy. The first article, beginning on page 110, discusses signs, symptoms, and triggering allergens.